Footnote: These questions are optional and your answers will not affect your entitlement to register or receive services from the NHS but may improve access to some NHS priority and service charities services
Not all doctors are authorised to dispense medicines
Select the option that best describes your ethnic group or background from the options below
Anybody in England can register with a GP practice and receive free medical care from that practice.
However, if you are not ‘ordinarily resident’ in the UK you may have to pay for NHS treatment outside of the GP practice. Being ordinarily resident broadly means living lawfully in the UK on a properly settled basis for the time being. In most cases, nationals of countries outside the European Economic Area must also have the status of ‘indefinite leave to remain’ in the UK.
Some services, such as diagnostic tests of suspected infectious diseases and any treatment of those diseases are free of charge to all people, while some groups who are not ordinarily resident here are exempt from all treatment charges.
More information on ordinary residence, exemptions and paying for NHS services can be found in the Visitor and Migrant patient leaflet, available from your GP practice.
You may be asked to provide proof of entitlement in order to receive free NHS treatment outside of the GP pract
Please tick one of the following boxes
A parent/guardian should complete the form on behalf of a child under 16.
Complete this section if you live in another EEA country, or have moved to the UK to study or retire, or if you live in the UK but work in another EEA member state. Do not complete this section if you have a GHIC or EHIC issued by the UK.
Please enter details from your EHIC or PRC below
Please give your S1 form to the practice staff.
How will your EHIC/PRC/S1 data be used? By using your EHIC or PRC for NHS treatment costs your EHIC or PRC data and GP appointment data will be shared with NHS secondary care (hospitals) and NHS Digital solely for the purposes of cost recovery. Your clinical data will not be shared in the cost recovery process.
Your EHIC, PRC or S1 information will be shared with The Department for Work and Pensions for the purpose of recovering your NHS costs from your home country.
Please detail below all regular medication you are currently taking (This includes ANY medication you regularly take including via private prescription or purchased via the internet/store). You will need to provide a repeat slip from your previous practice
If you take Benzodiazepines, Zopiclone or any drugs of dependence, you will be required to comply with the practice reduction program. By continuing with registration, you agree to comply with the practice reduction programme.
Please nominate a pharmacy so prescriptions can be sent electronically. You can then collect your medication from the nominated Pharmacy
Any new patients currently prescribed hypnotics (sleeping tablets) or anxiolytics included in the list of medicines below, will be placed on a withdrawal regime at the time of registration unless a GP feels this is not appropriate. THIS FORM MUST BE COMPLETED BY ALL PATIENTS WISHING TO REGISTER. FAILURE TO COMPLETE THIS SECTION WILL RESULT IN YOUR FORMS BEING RETURNED TO YOU AND YOUR REGISTRATION DELAYED.
Please choose a) OR b) below
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All Information submitted through secure forms is secured with a private key and is accessed over a secure connection by nominated staff. We have a strict confidentiality policy.
This information is not shared with any third party organisations.
This information is retained for up to 28 days.
I consent to my information being used for the purposes described above and wish to submit this online form to Accrington Branch • 387-391 Blackburn Road, Accrington, BB5 1RP.
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